Head injury classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Classification

Head injuries include both injuries to the brain and those to other parts of the head, such as the scalp and skull.

Head injuries may be closed or open. A closed (non-missile) head injury is one in which the skull is not broken. A penetrating head injury occurs when an object pierces the skull and breaches the dura mater. Brain injuries may be diffuse, occurring over a wide area, or focal, located in a small, specific area.

A head injury may cause a skull fracture, which may or may not be associated with injury to the brain. Some patients may have linear or depressed skull fractures.

If intracranial hemorrhage, or bleeding within the brain occurs, a hematoma within the skull can put pressure on the brain. Types of intracranial hematoma include subdural, subarachnoid, extradural, and intraparenchymal hematoma. Craniotomy surgeries are used in these cases to lessen the pressure by draining off blood.

Brain injury can be at the site of impact, but can also be at the opposite side of the skull due to a contrecoup effect (the impact to the head can cause the brain to move within the skull, causing the brain to impact the interior of the skull opposite the head-impact).

If the impact causes the head to move, the injury may be worsened, because the brain may ricochet inside the skull (causing additional impacts), or the brain may stay relatively still (due to inertia) but be hit by the moving skull.

Specific problems after head injury can include:

• Skull fracture
• Lacerations to the scalp and resulting hemorrhage of the skin
• Traumatic subdural hematoma, a bleeding below the dura mater which may develop slowly
• Traumatic extradural, or epidural hematoma, bleeding between the dura mater and the skull
• Traumatic subarachnoid hemorrhage
• Cerebral contusion, a bruise of the brain
• Concussion, a temporary loss of function due to trauma
• Dementia pugilistica, or "punch-drunk syndrome", caused by repetitive head injuries, for example in boxing or other contact sports
• A severe injury may lead to a coma or death

Concussion

Mild concussions are not associated with any sequelae. However, a slightly greater injury can be associated with both anterograde and retrograde amnesia (inability to remember events before or after the injury). The amount of time that the amnesia is present correlates with the severity of the injury. In some cases the patients may develop postconcussion syndrome, which can include memory problems, dizziness, and depression. Cerebral concussion is the most common head injury seen in children.

Epidural Hematoma

Epidural hematoma (EDH) is a rapidly accumulating hematoma between the dura mater and the cranium. These patients have a history of head trauma with loss of consciousness, then a lucid period, followed by loss of consciousness. Clinical onset occurs over minutes to hours. Many of these injuries are associated with lacerations of the middle meningeal artery. A "lenticular", or convex, lens-shaped extracerebral hemorrhage will likely be visible on a CT scan of the head. Although death is a potential complication, the prognosis is good when this injury is recognized and treated.

Subdural Hematoma

Subdural hematoma occurs when there is tearing of the bridging vein between the cerebral cortex and a draining venous sinus. At times they may be caused by arterial lacerations on the brain surface. Patients may have a history of loss of consciousness but they recover and do not relapse. Clinical onset occurs over hours. A crescent shaped hemorrhage compressing the brain will be noted on CT of the head. Surgical evacuation is the treatment. Complications include uncal herniation, focal neurologic deficits, and death. The prognosis is guarded.

Cerebral Contusion

Cerebral contusion is bruising of the brain tissue. The majority of contusions occur in the frontal and temporal lobes. Complications may include cerebral edema and transtentorial herniation. The goal of treatment should be to treat the increased intracranial pressure. The prognosis is guarded.

Diffuse Axonal Injury

Diffuse axonal injury, or DAI, usually occurs as the result of an acceleration or deceleration motion, not necessarily an impact. Axons are stretched and damaged when parts of the brain of differing density slide over one another. Prognoses vary widely depending on the extent of damage.